Provider Demographics
NPI:1023269446
Name:KOCH, ELIZABETH ALICE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ALICE
Last Name:KOCH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 WESTBROOK CORPORATE CTR
Mailing Address - Street 2:STE 800
Mailing Address - City:WESTCHESTER
Mailing Address - State:IL
Mailing Address - Zip Code:60154-5701
Mailing Address - Country:US
Mailing Address - Phone:708-343-3566
Mailing Address - Fax:
Practice Address - Street 1:1 WESTBROOK CORPORATE CTR
Practice Address - Street 2:STE 800
Practice Address - City:WESTCHESTER
Practice Address - State:IL
Practice Address - Zip Code:60154-5701
Practice Address - Country:US
Practice Address - Phone:708-343-3566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003308363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085003308Medicaid
IL1003856758OtherMEDICARE DUPAGE COUNTY
IL1770524670OtherMEDICARE ID- COOK CO
IL085003308Medicaid
IL207848Medicare PIN